Pre-Start Health Assessment Declaration
Personal Information
Full Name
Date
Role/Position
Work Location
Health Screening Questions
I do not currently have any fever, cough, sore throat, difficulty breathing, or other symptoms of illness.
I have not been in close contact with anyone diagnosed with a contagious illness in the last 14 days.
I am not currently awaiting results of a health test relevant to workplace safety.
I have not travelled internationally in the last 14 days.
Additional Comments
If you answered “No” to any question above or need to provide further details, please specify below:
Declaration
I declare that the above information is true and correct to the best of my knowledge.
Signature
Date